Antipsychotic drug presribing in dementia: changes from the pandemic
Authors: Clive Ballard, Anne Corbett
Journal: The Lancet Healthy Longevity (2023)

Christian Schnier and colleagues' Article1Schneir C McCarthy A Morales DR et al.Antipsychotic drug prescribing and mortality in people with dementia before and during the COVID-19 pandemic: a retrospective cohort study in Wales, UK.Lancet Healthy Longev. 2023; 4: 421-430Google Scholar in The Lancet Healthy Longevity reports on antipsychotic drug prescribing and mortality in a cohort of more than 50 000 people with dementia older than 60 years during the COVID-19 pandemic. The authors found that 11 929 (20·8%) of 57 396 individuals in the cohort were prescribed an antipsychotic medication at some point during the 67-month follow-up period, with very modest increments in antipsychotic drug prescribing, and with the largest increases seen in individuals younger than 65 years and care home residents. Several previous studies examining this issue generally showed small increases in prescribing rates, albeit with considerable variability and inconsistencies. A report based on UK national prescribing data suggested a modest but slightly larger increase of 9·3–10% during the pandemic.2Howard R Burns A Schneider L Antipsychotic prescribing to people with dementia during COVID-19.Lancet Neurol. 2020; 19: 892Summary Full Text Full Text PDF PubMed Scopus (40) Google Scholar One study including eight claims databases from six countries and data from more than 850 000 people older than 65 years with dementia reported large variations in pre-pandemic antipsychotic drug prescribing rates—between 7·8% and 40·6%.3Luo H Lau WCY Chai Y et al.Rates of antipsychotic drug prescribing among people living with dementia during the Covid-19 pandemic.JAMA Psychiatry. 2023; 80: 211-219Crossref Scopus (3) Google Scholar Increases in antipsychotics were reported in all eight databases, with a median baseline level of 19% and a median increase ranging between 2·1% and 21·1%. Notably, the proportion of people diagnosed with dementia each year of the follow-up varied substantially in this large international study. Furthermore, the prescribing rates in the two UK cohorts1Schneir C McCarthy A Morales DR et al.Antipsychotic drug prescribing and mortality in people with dementia before and during the COVID-19 pandemic: a retrospective cohort study in Wales, UK.Lancet Healthy Longev. 2023; 4: 421-430Google Scholar, 3Luo H Lau WCY Chai Y et al.Rates of antipsychotic drug prescribing among people living with dementia during the Covid-19 pandemic.JAMA Psychiatry. 2023; 80: 211-219Crossref Scopus (3) Google Scholar were substantially higher than that identified in the UK national prescribing data.2Howard R Burns A Schneider L Antipsychotic prescribing to people with dementia during COVID-19.Lancet Neurol. 2020; 19: 892Summary Full Text Full Text PDF PubMed Scopus (40) Google Scholar Another study focused specifically on nursing home residents with dementia.4McDermid J Ballard C Khan Z et al.Impact of the Covid-19 pandemic on neuropsychiatric symptoms and antipsychotic prescribing for people with dementia in nursing home settings.Int J Geriatr Psychiatry. 2023; 38: e5878Crossref Scopus (2) Google Scholar Although the sample size was much smaller (n=666), that study reported research-level data with an operationalised dementia diagnosis (one that was clinically confirmed using a standardised methodology).4McDermid J Ballard C Khan Z et al.Impact of the Covid-19 pandemic on neuropsychiatric symptoms and antipsychotic prescribing for people with dementia in nursing home settings.Int J Geriatr Psychiatry. 2023; 38: e5878Crossref Scopus (2) Google Scholar Comparison of antipsychotic drug prescribing reported in this study with data from a similar pre-pandemic study showed substantial variability between individual care homes, with an increase in prescription rates of more than 50% in a third of homes. Several considerations are important when interpreting the results from Schnier and colleagues' study. As in the UK prescribing data2Howard R Burns A Schneider L Antipsychotic prescribing to people with dementia during COVID-19.Lancet Neurol. 2020; 19: 892Summary Full Text Full Text PDF PubMed Scopus (40) Google Scholar and the Luo meta-analysis,3Luo H Lau WCY Chai Y et al.Rates of antipsychotic drug prescribing among people living with dementia during the Covid-19 pandemic.JAMA Psychiatry. 2023; 80: 211-219Crossref Scopus (3) Google Scholar the current study included very large datasets, but only clinically recorded diagnoses were used and substantial yearly variations in the proportion of people diagnosed with dementia were seen, which raises concerns of potential inaccuracies in the data. Additionally, prescription rates between different databases varied by a factor of nearly six times, suggesting either major differences in clinical practice or potential differences in data collection. Overall, despite considerable noise in the data, similar studies report an increase in prescribing, with absolute increases varying between 0·4% and 21·1%. Schnier and colleagues' study suggests that larger increases were seen among care home residents with dementia, an observation that is also supported by the pre-pandemic and post-pandemic WHELD studies.4McDermid J Ballard C Khan Z et al.Impact of the Covid-19 pandemic on neuropsychiatric symptoms and antipsychotic prescribing for people with dementia in nursing home settings.Int J Geriatr Psychiatry. 2023; 38: e5878Crossref Scopus (2) Google Scholar, 5Ballard C Orrell M Sun Y et al.Impact of antipsychotic review and non‐pharmacological intervention on health‐related quality of life in people with dementia living in care homes: WHELD—a factorial cluster randomised controlled trial.. Int J Geriatr Psychiatry. 2017; 32: 1094-1103Crossref PubMed Scopus (0) Google Scholar Mortality is a key issue in antipsychotic drug prescribing. Meta-analyses have indicated mortality increases of 1·5–1·7 times with atypical antipsychotics (eg, risperidone, olanzapine, and quetiapine) compared with placebo in Alzheimer's disease.6Schneider LS Pollock VE Lyness SA A meta-analysis of controlled trials of neuroleptic treatment in dementia.J Am Geriatr Soc. 1990; 38: 553-563Crossref PubMed Google Scholar, 7Ballard C Hanney ML Theodoulou M et al.The dementia antipsychotic withdrawal trial (DART-AD): long-term follow-up of a randomised placebo-controlled trial.Lancet Neurol. 2009; 8: 151-157Summary Full Text Full Text PDF PubMed Scopus (467) Google Scholar Previous randomised controlled trials have also shown that reducing antipsychotic drug prescribing also lowered mortality.8Ballard C Orrell M YongZhong S et al.Impact of antipsychotic review and nonpharmacological intervention on antipsychotic use, neuropsychiatric symptoms, and mortality in people with dementia living in nursing homes: a factorial cluster-randomized controlled trial by the well-being and health for people with dementia (WHELD) program.Am J Psychiatry. 2016; 173: 252-262Crossref PubMed Scopus (91) Google Scholar The relatively small increase in antipsychotic drug prescribing and the potential impact of COVID-19 on mortality in Schnier and colleagues' study makes this difficult to interpret. The potential impact on mortality of the changes in antipsychotic drug prescribing during the COVID-19 pandemic remains a key question for future studies, especially in vulnerable nursing home residents, in whom antipsychotic drug prescription rates are highest. Careful ongoing monitoring is needed to establish whether prescribing rates are returning to pre-COVID-19 levels, and identifying regional and local health services and nursing homes where local pressures have led to more substantial increases in antipsychotic use (and where tailored support services might be needed to restore best practice) will be important. Further work is also needed to ascertain the relationship between changes in real-world antipsychotic drug prescribing for people with dementia and mortality risk, which will then provide a better framework not just for prescription practices but also to establish the effect of changes in prescribing practice. With brexpiprazole now licensed in the USA for the treatment of agitation in people with Alzheimer's disease and approval in Europe likely to follow, reaching consensus regarding the safe and appropriate use of antipsychotics is increasingly urgent. CB has received consulting fees from Acadia, AARP, Addex, Eli Lily, Enterin, GWPharm, H Lundbeck, Novartis, Janssen, Johnson & Johnson, Novo Nordisk, Orion Corp, Otsuka America , Sunovion, Suven, Roche, Biogen, Synexus clinical research organisation, and tauX; and research funding from Synexus clinical research organisation, Roche, Novo Nordisk, and Novartis. AC has provided consultation to Acadia, Addex, Novartis, Janssen, and Sunovion and receives funding from Novo Nordisk and Synexus clinical research organisiation. Antipsychotic drug prescribing and mortality in people with dementia before and during the COVID-19 pandemic: a retrospective cohort study in Wales, UKDuring the COVID-19 pandemic, antipsychotic drug prescribing in people with dementia in the UK increased slightly; however, it is unlikely that this was solely related to the pandemic and this increase was unlikely to be a major factor in the substantial increase in mortality during 2020. The long-term increase in antipsychotic drug prescribing in younger people and in those with Alzheimer's disease warrants further investigation using resources with access to more granular clinical data. Although deprescribing antipsychotic medications remains an essential aspect of dementia care, the results of this study suggest that changes in prescribing and deprescribing practices as a result of the COVID-19 pandemic are not required. Full-Text PDF Open Access